Provider Demographics
NPI:1760464531
Name:STJERNHOLM, MELVIN R (MD)
Entity type:Individual
Prefix:
First Name:MELVIN
Middle Name:R
Last Name:STJERNHOLM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 40000
Mailing Address - Street 2:
Mailing Address - City:VAIL
Mailing Address - State:CO
Mailing Address - Zip Code:81658-7520
Mailing Address - Country:US
Mailing Address - Phone:970-668-8970
Mailing Address - Fax:970-470-6630
Practice Address - Street 1:323 WEST MAIN ST
Practice Address - Street 2:SUITE 101
Practice Address - City:FRISCO
Practice Address - State:CO
Practice Address - Zip Code:80443
Practice Address - Country:US
Practice Address - Phone:970-668-8970
Practice Address - Fax:970-470-6630
Is Sole Proprietor?:No
Enumeration Date:2005-11-17
Last Update Date:2017-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO15809207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01158096Medicaid
CO04007183Medicaid
COCM0288Medicare PIN
COC512798Medicare PIN
CO04007183Medicaid
CO080078975Medicare PIN